What can improvement contribute to solving the NHS productivity puzzle?

Everyone loves a good jigsaw. But for policymakers trying to solve the UK productivity puzzle, it might feel like someone has hidden the picture on the front of the box, and several of the pieces have gone missing. The comforting metaphor of the ‘puzzle’ – a predictable, solvable and repeatable game with clear rules, where pieces fit neatly together to produce a ‘right answer’ – seems inadequate for such a multi-dimensional, dynamic and complex issue.

The challenge is perhaps even greater when it comes to health services. NHS leaders, already seeking £22bn of efficiency improvements over the next five years, can’t have been cheered by our recent analysis showing that crude productivity in acute hospitals decreased sharply in 2012/13 and 2013/14. And for those delivering care at the front line, April signals a now familiar demand for savings of at least another 3.5% of budgets, all while the day-to-day pressure only grows in intensity, as funding fails to keep pace with rising demand, costs and expectations.  

The Five Year Forward View has filled in the outline of the response, calling for action on three fronts of demand, efficiency and funding. It seeks benefits from less efficient providers improving to match the best, new models of care of the kind embodied by the new vanguard sites, and improving the quality and responsiveness of care.

But while the vanguards understandably attract attention, these 29 sites can only go so far and so fast. In order to meet the scale of the challenge, improvement will be needed across the health and social care system. This improvement activity over the next five years must also help us build on the limited evidence base about what works to increase productivity at the same time as improving quality.

While we may not yet have the full answers to meeting the productivity challenge, the good news is that we know quality improvement is possible, and that we have gone some way to understanding what it takes to make successful change happen.

At the Health Foundation we have supported hundreds of frontline teams to improve quality – by which we mean care that is effective, safe, timely, person-centred, equitable and efficient. Reading evaluations of our extensive back catalogue in my first week as Director of Improvement, I am struck time and again by the ingenuity, skill and resilience of our grant holders and fellows.

For example, the projects described in our Flow Cost Quality programme demonstrate that a focus on the flow of patients between staff, departments and organisations along a pathway of care can have a far-reaching impact on quality.

In Sheffield, a fundamental reimagining of the process for emergency assessment, treatment and discharge of frail older people contributed to improvements in a number of important measures of quality of care, including discharge on the day, readmission rates and in-hospital mortality. These changes enabled a reduction in bed occupancy that contributed to financial savings of over £3m.

South Warwickshire’s work on improving flow in emergency care pathways also realised multiple benefits for patients and the Trust has continued to build on this work over time. Our report captures the richness and distinctiveness of these programs and is well worth review.

And there’s also our Shine programme. Through Shine we’ve supported dozens of projects that have improved quality and reduced costs through innovative approaches to organising services, creative use of data and technology, and enhancing education for staff and service users.

Improvement does not come easily. Academic evaluation of these programmes has identified the many common barriers these teams faced. But what seems critical in these projects is not the solutions they came up with, creative and effective though they were. It is the methodologies and mindsets that underpin them. These projects were made possible by dedicated teams who have the capabilities for improvement: the knowledge of how to develop ideas, and then plan, undertake, measure, and refine them; the skills to convince, share, overcome, connect, and lead; the funding and sheer determination to create the space and time to innovate.

On their own, these projects might amount to a relatively small contribution to the national picture, but they illustrate that under the right conditions, improvement is possible. Yet what is also striking is how many of these programmes have realised benefits in their local context, but how hard it has been to spread successful ideas. Drag and drop, this ain’t.

So if these approaches are to make a material contribution to quality, we have to increase rapidly our collective improvement capability, particularly at the regional and frontline level. We need to acknowledge the complexity of making change happen, and create the stability and the space – provide an occasional moment of silence amidst the deafening operational, regulatory and political noise – to allow us to think really creatively about how to make improvements, and how we spread and scale the interventions that we know work.

Our open call programmes in innovation, scale and spread are here to help, as are our leadership fellowships. I am greatly looking forward to learning more about the many exciting initiatives already underway, and working alongside you to develop new ways to support real improvements in the quality of health care.

Will is Director of Improvement at the Health Foundation, www.twitter.com/will_warburton2